Case 1
A 79-year-old male with severe aortic stenosis (AS) underwent AVR using a 23-mm, first-generation Trifecta valve in September 2015. Three years later, the patient presented with congestive heart failure, class III NYHA dyspnea, and severe aortic regurgitation (AR). After treatment for heart failure, platelets decreased to 10,000/μl, and idiopathic thrombocytopenic purpura was diagnosed, later found to be caused by Helicobacter pylori that was subsequently eradicated using antibiotics plus a proton pump inhibitor. Oral prednisolone and thrombopoietin receptor agonist were given two months before surgery to treat immune thrombocytopenia, with levels rising to 90,000/μl after treatment. An AVR using a 25-mm Inspiris Resilia aortic valve (Edwards Lifesciences LLC, Irvine, CA, USA) and a graft replacement of the ascending aorta with a 30-mm Dacron tube graft was performed. Intrasurgical findings revealed two leaflet tears at the bottom of the left coronary cusp and at the parastent part of the non-coronary cusp (fig.1). Recovery was uneventful and discharge occurred without any complications.